Inter-scalene ultrasound guided nerve block in ED
Date First Published:
November 14, 2016
Last Updated:
November 14, 2016
Report by:
JIa Song , F2 (Guys and St Thomas' Hospital )
Search checked by:
Jia Song, Guys and St Thomas' Hospital
Three-Part Question:
in [ patients needing shoulder reduction ] is [ Inter-scalene ultrasound guided nerve block done by emergency physicians in ED] offer better [ analgesia and clinical outcomes]
Clinical Scenario:
a patient presenting to A&E with simple shoulder dislocation. Should they receive a USS guided interscalene block or a procedural sedation for the joint reduction
Search Strategy:
Athens/Ovid search
'interscalene block' OR 'interscalene block shoulder dislocation'
and ' emergency'
'interscalene block' OR 'interscalene block shoulder dislocation'
and ' emergency'
Outcome:
Blaivas, M., Adhikari, S. & Lander, L. A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department. Acad. Emerg. Med. Off. J. Soc. Acad. Emerg. Med. 18, 922–927 (2011).
Blaivas, M. & Lyon, M. Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED. Am. J. Emerg. Med. 24, 293–296 (2006).
Bhoi, S. et al. Feasibility and safety of ultrasound-guided nerve block for management of limb injuries by emergency care physicians. J. Emerg. Trauma Shock 5, 28–32 (2012).
Bhoi, S., Chandra, A. & Galwankar, S. Ultrasound-guided nerve blocks in the emergency department. J. Emerg. Trauma Shock 3, 82–88 (2010).
Blaivas, M. & Lyon, M. Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED. Am. J. Emerg. Med. 24, 293–296 (2006).
Bhoi, S. et al. Feasibility and safety of ultrasound-guided nerve block for management of limb injuries by emergency care physicians. J. Emerg. Trauma Shock 5, 28–32 (2012).
Bhoi, S., Chandra, A. & Galwankar, S. Ultrasound-guided nerve blocks in the emergency department. J. Emerg. Trauma Shock 3, 82–88 (2010).
Relevant Paper(s):
Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
---|---|---|---|---|---|
A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department Blaivas, M., Adhikari, S. & Lander 2011 USA | 42 ED patients presenting with shoulder dislocation Inclusion criteria: >18 yrs old Exclusion: known local anesthetic allergy, hemodynamic instability, resp distress, altered mental status 21 randomized to US, 21 to sedation. |
Prospective randomized study (1+) |
Length of stay (primary outcome | Sedation = 177.3 (+/-37.9), US = 100.3 (+/-28.2). P <. 0001 | No blinding No measurement of other variables that might affect length of stay (e.g. time to x-ray) Convenience sample design (i.e. no all that presents) Single center study |
One-on-one health provider time (min | Sedation= 47.1 (+/-9.8), US = 5 (+/-0.7). P<.000 | ||||
Pain experiences during reduction (median) | Sedation = 0 (0-4), US= 0 (0-3). P=.9275 | ||||
Patient satisfaction | Sedation = 8.2 (+/-1.3), Us= 8.3 (+/-1). P=.7990 | ||||
Complication (hypotension, hypoxia) | No difference p=.49 | ||||
Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED. Blaivas, M. & Lyon, M 2006 USA | 4 patients cases needing shoulder reduction, where conscious sedation was not possible |
case reports (level 3) | Complete anesthesia and muscle relaxation allow comfortable reduction | obtained in all cases,1 case of temporary recurrent laryngeal nerve palsy | V small numbers No statistical comparison Total length of stay not reported Level of expertise and training of ED physician not reported |
Bhoi, S. et al. Feasibility and safety of ultrasound-guided nerve block for management of limb injuries by emergency care physicians Bhoi, Chandra& Galwankar. 2010 India | 8 patients over period of 3 weeks Various specialty doctors including ED residents assigned to ED |
Case report (3) |
If US guided upper and lower extremity peripheral nerve blockage were feasible in ED setting | Different patients with different injuries, complexities Different specialty and grade of trainee | Different patients with different injuries, complexities Different specialty and grade of trainee |
Ultrasound-guided nerve blocks in the emergency department Bhoi, S., Chandra, A. & Galwankar, S. 2010 India | 50 patients (7-80 yrs) with limb injury needing procedural sedation Various specialty doctors including ED residents assigned to ED |
Prospective observational study (2-) |
% of cases completed without rescue analgesia Median reduction in pain (primary)* | None; Reduction of 7.44 (p=.00001 | Observational No blinding No control |
* 2nd outcome: complication immediate or late at 3month | none. Median procedure time – 9min, median reduction of pain 5min | ||||
A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department Blaivas, M., Adhikari, S. & Lander 2011 USA | 42 ED patients presenting with shoulder dislocation Inclusion criteria: >18 yrs old Exclusion: known local anesthetic allergy, hemodynamic instability, resp distress, altered mental status 21 randomized to US, 21 to sedation. |
Prospective randomized study (1+) |
No blinding No measurement of other variables that might affect length of stay (e.g. time to x-ray) Convenience sample design (i.e. no all that presents) Single center study |
Author Commentary:
1) US- guided interscalene nerve block for shoulder dislocation
Blaivas, Adhikari & Lander (2011):
Training received probably more than an average ED physician
Specialized training in USS regional anesthesia
- (2 hour didactic course + hands on training. All at least 2 year experience in US. Each preformed at least 10 interscalene block before)
Clear inclusion and exclusion criteria. All subjects presented with simple dislocation.
Might not be suitable for more complex injuries
Clinical relevance:
US guided interscalene nerve block appear to have similar effectiveness and safety as traditional method
Cost effectiveness:
US guided interscalene nerve block appear to offer speedier recovery time and require less personnel resource
2)Can emergency doctors be trained to perform this technique effectively and safely?
Blaivas & Lyon, 2006
Level of expertise and training of ED physician not reported
Blaivas, Adhikari & Lander, 2011
Specialized training in USS regional anesthesia (2 hour didactic course + hands on training)
All at least 2 year experience in US. Each preformed at least 10 interscalene block before)
Bhoi, Chandra & Galwankar (2010)
Training seminar on US guided upper an lower peripheral nerve block
2/8 were anterior scalene block for shoulder dislocation. both reported complete anesthesia, dischaged after 1h observation
Bhoi et al (2012)
One hour diactic session and practice on live model
One week practice for of nerve identification under superviion.
Minimum of 5 US- guided nerve blocks on nerve model (Blue phantom
24% brachial plexus block 13 shoulder reductions
Blaivas, Adhikari & Lander (2011):
Training received probably more than an average ED physician
Specialized training in USS regional anesthesia
- (2 hour didactic course + hands on training. All at least 2 year experience in US. Each preformed at least 10 interscalene block before)
Clear inclusion and exclusion criteria. All subjects presented with simple dislocation.
Might not be suitable for more complex injuries
Clinical relevance:
US guided interscalene nerve block appear to have similar effectiveness and safety as traditional method
Cost effectiveness:
US guided interscalene nerve block appear to offer speedier recovery time and require less personnel resource
2)Can emergency doctors be trained to perform this technique effectively and safely?
Blaivas & Lyon, 2006
Level of expertise and training of ED physician not reported
Blaivas, Adhikari & Lander, 2011
Specialized training in USS regional anesthesia (2 hour didactic course + hands on training)
All at least 2 year experience in US. Each preformed at least 10 interscalene block before)
Bhoi, Chandra & Galwankar (2010)
Training seminar on US guided upper an lower peripheral nerve block
2/8 were anterior scalene block for shoulder dislocation. both reported complete anesthesia, dischaged after 1h observation
Bhoi et al (2012)
One hour diactic session and practice on live model
One week practice for of nerve identification under superviion.
Minimum of 5 US- guided nerve blocks on nerve model (Blue phantom
24% brachial plexus block 13 shoulder reductions
Bottom Line:
US- guided interscalene nerve block can be safely and effectively performed by emergency physicians with adequate training.
For simple Shoulder dislocation it had similar clinical effectiveness and safety as traditional method, with the added benefit of a speedier recovery time and less personnel resource.
For simple Shoulder dislocation it had similar clinical effectiveness and safety as traditional method, with the added benefit of a speedier recovery time and less personnel resource.
References:
- Blaivas, M., Adhikari, S. & Lander. A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department
- Blaivas, M. & Lyon, M. Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED.
- Bhoi, Chandra& Galwankar. . Bhoi, S. et al. Feasibility and safety of ultrasound-guided nerve block for management of limb injuries by emergency care physicians
- Bhoi, S., Chandra, A. & Galwankar, S. . Ultrasound-guided nerve blocks in the emergency department
- Blaivas, M., Adhikari, S. & Lander. A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department